Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
What is your standard approach (i.e. choice of medication, type of sheath) in the cath lab to reduce the likelihood of radial artery spasm?
Adrenaline is the key vasoconstrictor here, especially in patients with vessels prone to repetitive nicotine-induced constriction, so conscious sedation helps blunt the ‘fright/flight/constrict’ of adrenaline, while a CCB vasodilator (verapamil or nicardipine) addresses local vasoconstriction. A sma...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...
What are alternate approaches to medical therapy and/or interventions to consider in patients with refractory, severe coronary vasospasm despite short-acting nitrates, calcium channel blockers, L-arginine, and clonidine?
Angina caused by coronary vasospasm is relatively rare. I have come across very few cases of severe coronary vasospasm in my 15 years of career. The most common thread seems to be smoking and drug abuse (amphetamines, cocaine). Smoking cessation and stopping drug abuse are the most important interve...
Can Droxidopa be used for augmenting orthostatic hypotension treatment in patients who are already on midodrine and/or fludrocortisone?
I routinely combine droxidopa with fludrocortisone just as I would midodrine and fludrocortisone when orthostatic hypotension is refractory to tolerated doses of monotherapy. The use of droxidopa and midodrine is something I do less commonly, or frankly just rarely. They compete for the same recept...
Do you favor Sotagliflozin over SGLT2i alone for cardiovascular risk reduction in patients with Type 2 diabetes and chronic kidney disease?
The use of Sotagliflozin rather than SGLT2i alone is reasonable based on the results of the SCORED trial (Aggarwal et al., PMID 39961315). Although this trial compared sotagliflozin to placebo, rather than to SGLT2i, it did show a reduction in both MI and stroke in patients who have type 2 diabetes ...
Would you consider an ICD for secondary prevention in an otherwise previously healthy adult found to have severe LV systolic dysfunction admitted s/p VF/VT arrest due to profound hypokalemia and hypomagnesemia, or defer implantation given resolution of arrhythmias after correcting electrolyte abnormalities?
I would need to have much more information. For example, does this person have CAD and/or a definable etiology for the cardiomyopathy? Does he/she/they have a family history or genetic profile that might influence the decision. Importantly, I would not dismiss a secondary ICD in this person based on...
How do you approach management of recurrent idiopathic pleuropericarditis?
The first line is colchicine and NSAIDs until the pain resolves, CRP normalizes, etc… After this, if the CRP tracks with the symptoms, fluid reaccumulation, and/or cMRI evidence of the pericarditis, I find il-1 inhibitors work very well.
Would the diagnostic yield for ABIs or peripheral arterial duplex doppler in a patient with metal rods in both legs be similar or acceptable in comparison to those tests in a patient without metal rods?
Ankle-brachial index(ABI) relies on the compression of upper and lower extremity arteries with blood pressure cuffs and measuring the ratio of blood pressure between them. While I am not aware of specific studies in those with metallic rod fixation, ABI measurements should have similar utility as lo...
What is a reasonable class of antihypertensive to start in patients with HCM who remain hypertensive and symptomatic in spite of maximal doses of beta blockade or calcium channel blockers?
My answer is based on the experience and not the research data per se in HCM: I will add low-dose HCTZ (12.5 mg daily). It won't cause dehydration or hypokalemia and might do wonders in managing HTN in these patients. One of the cheapest and most effective! Or I would consider Spironolactone instea...